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A 60-year-old woman with autism and a repetitive swallowing behavior ingested a removable partial denture that impacted in the proximal esophagus. Attempts at endoscopic removal were unsuccessful. Esophageal perforation was recognized, necessitating emergency transcervical surgical exploration, esophagotomy with foreign body removal, and repair of the esophageal perforation. She had a prolonged postoperative stay involving mechanical ventilatory support and gastric tube feeds. This situation was predictable and preventable, and application of key principles may help avoid such catastrophic incidents in similar patients., (Copyright © 2021 Editorial Council for the Journal of Prosthetic Dentistry. Published by Elsevier Inc. All rights reserved.)

Background: The indeterminate pulmonary nodule is a common clinical problem. Preoperative tissue diagnosis is not always possible, despite all attempts. The objectives of this study were to determine the frequency of a malignant diagnosis in this scenario and whether attempted preoperative biopsy impacted estimation of the risk of malignancy., Patients and Methods: We reviewed 500 consecutive cases of pulmonary resection without a preoperative tissue diagnosis at a tertiary care center from 2009 to 2013. Age, sex, smoking status, prior malignancy, tumor size, and whether or not tissue diagnosis had been attempted were recorded. Logistic regression models were constructed to determine factors associated with a malignant diagnosis., Results: There were 297 males (59.4%), the mean age was 64.9 years, and 412 had a smoking history (82.4%). Also, 203 patients (40.6%) had a malignancy history, and 36 patients (7.2%) had previous lung cancer. Biopsy was attempted for 102 patients (20.5%). The final diagnosis was lung cancer in 336 patients (67.2%), metastatic cancer in 93 patients (18.6%), and benign tumour in 71 patients (14.2%). Male sex, increasing age, smoking history, and prior lung cancer were positive predictors of lung cancer. Model discrimination was good (c-statistic, 0.83). Attempted biopsy did not alter model discrimination., Conclusion: In this cohort, 86% of resected lesions were malignant. The decision to pursue preoperative tissue diagnosis did not change the predictive ability offered by clinical factors. These findings are reassuring in the scenario when a patient is operable but the diagnosis remains unknown., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: The acute care surgery (ACS) model has been shown to improve patient, hospital and surgeon-specific outcomes. To date, however, little has been published on its impact on residency training. Our study compared the emergency general surgery (EGS) operative experiences of residents assigned to ACS versus elective surgical rotations., Methods: Resident-reported EGS case logs were prospectively collected over a 9-month period across 3 teaching hospitals. Descriptive statistics were tabulated and group comparisons were made using χ2 statistics for categorical data and t tests for continuous data., Results: Overall, 1061 cases were reported. Resident participation exceeded 90%). Appendiceal and biliary disease accounted for 49.7% of EGS cases. Residents on ACS rotations reported participating in twice as many EGS cases per block as residents on elective rotations (12.64 v. 6.30 cases, p < 0.01). Most cases occurred after hours while residents were on call rather than during daytime ACS hours (78.8% v. 21.1%, p < 0.01). Senior residents were more likely than junior residents to report having a primary operator role (71.3% v. 32.0%, p < 0.01). Although the timing of cases made no difference in the operative role of senior residents, junior residents assumed the primary operator role more often during the daytime than after hours (50.0% v. 33.1%, p = 0.01)., Conclusion: Despite implementation of the ACS model, residents in our program obtained most of their EGS operative experience after hours while on call. Although further research is needed, our study suggests that improved daytime access to the operating room may represent an opportunity to improve the quantity and quality of the EGS operative experience at our academic network., Competing Interests: T. Rice has received speaker fees from Cook Medical, unrelated to the present work. No other competing interests declared., (© 2021 CMA Joule Inc. or its licensors.)

Background: Despite the widespread implementation of the acute care surgery (ACS) model, limited access to operating room time represents a barrier to the optimal delivery of emergency general surgery (EGS) care. The objective of this study was to describe the effect of operative timing on outcomes in EGS in a network of teaching hospitals., Methods: We conducted a retrospective review of EGS operations performed at 3 teaching hospitals in a single academic network. Time of operation was categorized as daytime (8 am to 5 pm), after hours (5 pm to 11 pm) or overnight (11 pm to 8 am). Time to operation was calculated as the interval from admission to operative start time and categorized as less than 24 hours, 24-72 hours and greater than 72 hours., Results: After we excluded nonindex cases, trauma cases and cases occurring more than 5 days after admission, 1505 EGS cases were included. We found that 39.0% of operations were performed in the daytime, 46.3% after hours and 14.8% overnight. In terms of time to operation, 52.3% of operations were performed within 24 hours of admission, 33.4% in 24-72 hours and 14.3% in more than 72 hours. The overall complication rate was 20.6% (310 patients) and the overall mortality rate was 3.8% (57 patients). After multivariable analysis, time to operation more than 72 hours after admission was independently associated with increased odds of morbidity (odds ratio [OR] 1.64, 95% confidence interval [CI] 1.09-2.47), while overnight operating was associated with increased odds of death (OR 3.15, 95% CI 1.29-7.70)., Conclusion: Increasing time from admission to operation and overnight operating were associated with greater morbidity and mortality, respectively, for EGS patients. Strategies to provide timely access to the operating room should be considered to optimize care in an ACS model., Competing Interests: T. Rice has received speaker fees from Cook Medical. No other competing interests were declared., (© 2020 Joule Inc. or its licensors.)

Background: The Tokyo Guidelines were published in 2007 and updated in 2013 and 2018, with recommendations for the diagnosis and management of acute cholecystitis. We assessed guideline adherence at our academic centre and its impact on patient outcomes., Methods: This is a retrospective chart review of patients with acute calculous cholecystitis who underwent cholecystectomy at our institution between November 2013 and March 2015. Severity of cholecystitis was graded retrospectively if it had not been documented preoperatively. Compliance with the Tokyo Guidelines' recommendations on antibiotic use and time to operation was recorded. Cholecystitis severity groups were compared statistically, and logistic regression was used to determine predictors of complications., Results: One hundred and fifty patients were included in the study. Of these, 104 patients were graded as having mild cholecystitis, 45 as having moderate cholecystitis, and 1 as having severe cholecystitis. Severity was not documented preoperatively for any patient. Compliance with antibiotic recommendations was poor (18.0%) and did not differ by cholecystitis severity (p = 0.90). Compliance with the recommendation on time to operation was 86.0%, with no between-group differences (p = 0.63); it improved when an acute care surgery team was involved (91.0% v. 76.0%, p = 0.025). On multivariable analysis, comorbidities (odds ratio [OR] 1.47, 95% confidence interval [CI] 1.19-1.85, p < 0.001) and conversion to laparotomy (OR 13.45, 95% CI 2.16-125.49, p = 0.01) predicted postoperative complications, while severity of cholecystitis, antibiotic compliance and time to operation had no effect., Conclusion: In this study, compliance with the Tokyo Guidelines was acceptable only for time to operation. Although the poor compliance with recommendations relating to documentation of severity grading and antibiotic use did not have a negative affect on patient outcomes, these recommendations are important because they facilitate appropriate antibiotic use and patient risk stratification., Competing Interests: None declared., (© 2020 Joule Inc. or its licensors.)

Background: Benchmarking operative volume and resources is necessary to understand current efforts addressing thoracic surgical need. Our objective was to examine the impact on thoracic surgery volume and patient access in Rwanda following a comprehensive capacity building program, the Human Resources for Health (HRH) Program, and thoracic simulation training., Methods: A retrospective cohort study was conducted of operating room registries between 2011 and 2016 at three Rwandan referral centers: University Teaching Hospital of Kigali, University Teaching Hospital of Butare, and King Faisal Hospital. A facility-based needs assessment of essential surgical and thoracic resources was performed concurrently using modified World Health Organization forms. Baseline patient characteristics at each site were compared using a Pearson Chi-squared test or Kruskal-Wallis test. Comparisons of operative volume were performed using paired parametric statistical methods., Results: Of 14,130 observed general surgery procedures, 248 (1.76%) major thoracic cases were identified. The most common indications were infection (45.9%), anatomic abnormalities (34.4%), masses (13.7%), and trauma (6%). The proportion of thoracic cases did not increase during the HRH program (2.07 vs 1.78%, respectively, p = 0.22) or following thoracic simulation training (1.95 2013 vs 1.44% 2015; p = 0.15). Both university hospitals suffer from inadequate thoracic surgery supplies and essential anesthetic equipment. The private hospital performed the highest percentage of major thoracic procedures consistent with greater workforce and thoracic-specific material resources (0.89% CHUK, 0.67% CHUB, and 5.42% KFH; p < 0.01)., Conclusions and Relevance: Lack of specialist providers and material resources limits thoracic surgical volume in Rwanda despite current interventions. A targeted approach addressing barriers described is necessary for sustainable progress in thoracic surgical care.

A subclinical form of slipped capital femoral epiphysis (SCFE) can lead to subtle morphologic abnormalities, such as cam-type femoroacetabular impingement (FAI). Femoroacetabular impingement is a mechanical hip abnormality that typically affects young populations and leads to hip pain and premature osteoarthritis. Imaging is critical to diagnosis, whether by radiograph, magnetic resonance imaging, or computed tomography. The authors investigated the use of imaging to detect characteristics of subclinical SCFE and cam-type FAI in patients undergoing hip resurfacing. They retrospectively assessed computed tomography scans of 81 hips from 75 patients. Measurements were taken of the proximal femur and included the alpha angle, head-neck tilt, and anterior offset taken in both the conventional oblique axial plane and the radial plane. The cohort consisted of 68 men and 13 women with an average age of 52 years. Ninety percent of hips on the oblique axial view and 95% of hips on the radial view were found to have pathologically increased alpha angles. Negative correlations were found between the alpha angle and head-neck tilt and positive correlations between head-neck tilt and anterior offset ratio. Sixty percent and 68% of hips in the oblique axial and radial planes, respectively, were abnormal for the alpha angle, head-neck tilt, and anterior offset ratio, strongly suggesting SCFE morphology. This study's results show similarity in morphology between cam-type FAI and SCFE, known precursors to osteoarthritis, in an early arthritic patient population., (Copyright 2013, SLACK Incorporated.)

One marker for early-onset hip arthritis is femoral acetabular impingement. The current standard way of quantifying impingement is manual calculation of anatomical measures on plain radiographs, including the α-angle. Such measurements are user-dependent and prone to error. We provided a robust computational alternative and proposed using numerical fitting of geometrical shapes. We applied least-squares fitting of an ellipse to the femoral head contour and used the difference between the ellipse axes as a quantification method. The results showed a good correlation between the new measure and previous definitions of the α-angle.